=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932587078
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS ARMAND ROTOLO PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2015
-----------------------------------------------------
Last Update Date | 05/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 HOPE AVE STE 107
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02453-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-847-9642
-----------------------------------------------------
Fax | 781-609-7408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 WELLINGTON ST APT 3
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-3649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-847-9642
-----------------------------------------------------
Fax | 781-609-7408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 10670
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 10670
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------